The same worker also rolled another dementia patient into a wall while changing bedding, causing knee bruising, inspectors found at Skiatook Nursing Home during a November complaint investigation.
When the administrator tried to question the nursing assistant about the incidents by phone, the worker "became belligerent, and stated they were quitting," according to the inspection report.
The abuse occurred on the evening shift of July 27, but wasn't reported to administrators until the next day when another nursing assistant witnessed the incidents and called to report them.
CNA #2 told administrators that CNA #1 "got in Resident #1's personal space and forced them to sit on the toilet," according to the incident report dated July 28. After the resident pushed back against the nursing assistant, "CNA #1 pushed the resident back."
The same evening, the reporting nursing assistant witnessed CNA #1 "rolled Resident #2 into the wall while changing the resident's bedding." The impact caused Resident #2 to "hit their knees on the wall, causing some discoloration to their knees."
Both victims suffered from cognitive impairment that left them vulnerable. Resident #1 had diagnoses including dementia and Alzheimer's disease, with a quarterly assessment from November 13 showing they were "severely cognitively impaired" with a cognitive score of just 2 out of 15 points.
Resident #2 had diagnoses including dementia, anxiety, and obsessive-compulsive disorder. A November 6 assessment classified them as "moderately cognitively impaired" with a cognitive score of 9.
The facility's own policy defines abuse as "the willing infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish." Federal inspectors determined both incidents met this definition.
The administrator confirmed the details during an interview with inspectors on November 18. They stated that CNA #2 had called on July 28 to report that "CNA #1 was rough with Resident #1 by forcing them down onto the toilet" during the previous evening's shift.
The administrator also confirmed that "Resident #1 pushed CNA #1 and CNA #1 pushed the Resident #1 back," and that the nursing assistant had "rolled Resident #1 into the wall causing bruising to the resident's knees" while changing bedding for the second victim.
The administrator's attempt to investigate by calling the accused nursing assistant proved futile. When questioned about the incidents over the phone, the worker's response was to become confrontational and announce their resignation rather than provide an explanation.
Following the incidents, the administrator stated they conducted "in-services with the staff regarding abuse," but the inspection report provides no details about the scope or content of this training.
The timing of the report raises questions about the facility's incident response procedures. The abuse occurred on July 27, but administrators weren't notified until July 28 when the witnessing nursing assistant made the call. The inspection report doesn't indicate whether the facility has policies requiring immediate reporting of suspected abuse or what delayed the initial report by a full day.
The facility houses 32 residents according to the Director of Nursing, making the abuse of two cognitively impaired residents a significant proportion of the vulnerable population under the facility's care.
Federal regulations require nursing homes to protect residents from all forms of abuse, including physical abuse, mental abuse, and neglect. The regulation is designed to ensure that residents, particularly those with cognitive impairments who may be unable to report abuse themselves, receive protection from harm by staff members.
The inspection found the facility failed to meet this fundamental protection requirement for two of the three residents reviewed for potential abuse incidents. Inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
The physical evidence of abuse was documented in both cases. Resident #1 was subjected to forced physical positioning and retaliatory pushing after they attempted to resist the inappropriate treatment. Resident #2 sustained visible knee discoloration from being rolled into the wall with sufficient force to cause bruising.
Both residents' cognitive impairments would have made them particularly vulnerable to abuse and potentially unable to report the incidents themselves. Resident #1's severe cognitive impairment, evidenced by scoring just 2 points on a 15-point cognitive assessment, would have left them largely unable to understand or communicate about their treatment.
The fact that another nursing assistant witnessed both incidents and took the initiative to report them the following day suggests the abuse was obvious enough to be unmistakable to observers. However, the report doesn't indicate whether other staff members were present during the incidents or why the reporting was delayed until the next day.
The accused nursing assistant's immediate resignation when questioned suggests an awareness that their actions were inappropriate and potentially criminal. Rather than providing an explanation or denying the allegations, the worker chose to quit and become "belligerent" when approached by administrators.
The facility's response of conducting staff training on abuse prevention occurred only after the incidents were reported, raising questions about whether adequate training and supervision were in place to prevent the abuse from occurring initially.
For residents with dementia and cognitive impairments, nursing home care requires specialized training and patience. These residents may exhibit behaviors that challenge staff, but federal regulations and professional standards require that care providers respond with appropriate techniques rather than force or retaliation.
The inspection occurred in November, four months after the July incidents, as part of a complaint investigation. The report doesn't specify who filed the complaint or whether additional incidents had occurred in the interim period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skiatook Nursing Home,llc from 2025-11-26 including all violations, facility responses, and corrective action plans.